4 Labour and birth - IEmpowermentiempowerment.org/usb/iempowerment/healthcare/Health_Womens_Business...Labour and birth 4 Labour and birth ... Retained placenta ... Manual, 5th ed

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4 Labour and birth

Introduction �� 164Birth and resuscitation equipment �� 166Labour and birth �� 169

First stage of labour �� 170Second stage of labour �� 172Third stage of labour �� 177Rubbing up a contraction �� 180

Checking the placenta �� 181MotherCare of mother for first 24 hours after the birth �� 182Tears of the birth canal �� 184Repairing tear or episiotomy �� 187Retained placenta �� 189BabyAPGAR Score�� 191Keeping baby warm after birth �� 193

Using incubator or overhead heater �� 194Care of normal newborn for first 24 hours �� 196Birth registration forms �� 199Stillbirth �� 200

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164 Labour and birth

Introduction

In traditional Aboriginal culture, birthing is strictly the concern of women and governed by Women's Law. Many older women and traditional birth attendants have this knowledge — 'Grandmother's Law'. Older women and traditional birth attendants talk about birthing in country, with babies connected by birth and ritual to that country.

Traditionally, women gave birth well away from camps. Women birthed alone or were looked after by birth attendants or female relatives of the right skin. Rules determining which relatives are 'right skin' vary by region. Women stayed isolated for up to a week after birth. Appropriate relatives visited, bringing special food like kangaroo, sweet potato, wild bananas. Father usually did not see mother or baby during this time.

Women relied on fire for warmth and healing. After the birth, traditional practices focused on stopping bleeding , healing, warming, and making mother and baby spiritually strong. Traditional ceremonies included smoking ceremonies for baby and mother. Traditional practices governed how the cord was managed, including cord being cut after placenta delivered, cut longer than normal, crushed with a stone instead of being cut, tied with hair or string. A long strand of cord may be put around baby's neck.

Managing the placenta is of traditional importance. Old women say the placenta is sacred and should not be handled. In the old days, placenta was buried in hole at birth site, often dug by mother, then good hot fire lit on top.

Women may wish to follow some traditional practices on return to community.

Birthing placesWomen from remote communities are strongly encouraged to birth in regional hospital, in line with health service policies. Give information during antenatal period to prepare woman for this. Include advice about living and hospital arrangements, birth experience, having support people with her.

Birthing in hospital may be isolating and frightening due to unfamiliar staff, strange surroundings, language barriers. Strategies to overcome these fears include a tour of labour ward and postnatal area, having interpreter available, meeting maternity unit staff, identifying family or others in town who can support woman while she waits.

Lack of knowledge of the birth experience can contribute to fear and feelings of isolation. Knowledge and preparation can reduce fear, the unknown may not seem so daunting. Education is an important part of antenatal care�

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165Labour and birth

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Introduction

After birth in hospital — in Alice Springs woman can go to Congress Alukura for traditional ceremonies, or have ceremonies when she returns to her community.

Unexpected births 'out bush'Births still occur unexpectedly in remote communities. Sometimes women don't agree with 'birthing in hospital', for a variety of personal reasons and beliefs. Occasionally baby is born in the bush with birth assistants supporting woman and practising Law and culture. Clinic staff may only find out when labour is well established or after baby is born.

If woman presents in labour , talk with midwife and clinic/referral doctor. May be asked to suppress labour so woman can be sent to hospital. If no time to send her to hospital, try to close clinic. Birthing is still private. Ask ATSIHPs or AHWs what is appropriate practice in this community.

Woman can choose relatives and birth attendants to support her. Clinic staff should try to work with these women in an open, cooperative way. Birth attendants skilled at massage, easing pain by rubbing woman's back, encouraging baby to be born by rubbing woman's belly, and have a store of knowledge and beliefs to help woman in labour .

After delivery and check of placenta, ask ATSIHP, AHW or birth attendants what to do with placenta, eg check if it can be kept in fridge or freezer. One option might be to bury it in health centre grounds with or without a fire. Old women are worried that placentas are burned in clinic rubbish bins, buried so that dogs can get to them, or stored in freezers causing sickness from the cold to enter mothers.

Cultural practices may occur after birth in community. Health staff need to be aware of these customs so they do not unwittingly interfere. Staff may sometimes be invited to attend and participate.

Mother and baby may still need to be sent to hospital for postnatal care. If not, ATSIHPs, AHWs, woman, and relevant family members should decide where woman will stay and who is allowed to see her after the birth.

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Birth and resuscitation equipment

BirthBirthing pack (delivery/midwifery pack)

• Sterile lubricant • Sterile sharp curved blunt-ended scissors for episiotomy • 2 sterile metal clamps with ratchets and grazed ends for clamping cord • Sterile blunt-ended scissors for cutting cord • Urinary catheter equipment • Small combine dressings • Kidney dish for placenta • Sponge holding forceps for membranes • Suture materials (CPM p312) • Equipment for taking cord blood (p177)

General equipment • Box of non-sterile gloves. May need to change them often • Goggles or other eye protection • Plastic apron to protect your clothes • Lots of blueys, spare sheets • Good light

Medicines • Oxytocin (eg Syntocinon) 10units/ml (5 ampoules), 2ml syringe, 23G needle • Lignocaine 1% (5 ampoules)

After the birth • Wraps for baby — towels to dry, warmed blankets, bubble wrap, cling wrap,

space blankets. See Keeping baby warm after birth (p193) • 2 plastic cord clamps, and 2 spares in case first break • Name bands for baby x 4 • Plastic bucket with lid or plastic bags for placenta — family may want to take it • Thermometer, under arm (axillary) • Paediatric vitamin K (eg Konakion) 2mg/0.2ml, 1ml syringe, 25G needle • Birth registration forms

General equipment — mother and baby • BP machine • Stethoscope • Thermometer

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167Labour and birth


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• Fetal heart doppler, pinard stethoscope • Clock with second hand • Blood specimen tubes — EDTA, plain • Syringes 1ml, 2ml, 5ml, 10ml x 5 each • Needles 19–26G • Normal saline, tourniquet, tape • IV giving sets (blood/fluid pump sets) • IV cannula — 14–24G • IV bungs, extension tubing, IV dressings • IO needle device • IO needles, 15mm (baby), 25mm (adult), 45mm (obese) • Nasogastric tubes 5F, 6F, 8F

Resuscitation — mother • Oxygen/medical air with flowmeter (flow rates up to 10L/min) • Resuscitation bag and mask, nasal prongs with oxygen tubing • Mechanical suction and tubing • Yankauer sucker • Emergency trolley

Resuscitation — newbornWarmth

• Warm towels and baby wraps, space blanket

Airway and breathing equipment • Oxygen/medical air with flowmeter (flow rates up to 10 L/min) • Infant mask and oxygen tubing. Can used cupped hand if not available • Oxygen saturation monitor (oximeter) with infant probe • Resuscitation bag and mask, sizes 0, 00 — assemble and check before birth

Suction • Mechanical suction (low pressure if possible) and tubing • Suction catheters, sizes 8F, 10F, 12F

IntubationUse only if skilled in advanced neonatal resuscitation.

• Laryngoscope with straight blades, sizes 0, 1 ◦ Extra bulbs and batteries for laryngoscope

• Endotracheal tubes 2.0, 2.5, 3.0, 3.5, 4.0, 4.5mm

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• Stylette or introducer • Tape for securing tube, eg Elastoplast

MedicinesUse only under medical advice

• Adrenaline 1:10 000 (0.1 mg/ml) • Normal saline 30ml • Glucose 5% and glucose 10%, 500ml • Water for injection 5ml

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169Labour and birth

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Labour and birth

Most births are planned for a regional centre. This protocol describes care of woman having normal but unexpected birth in primary health care setting.

• If birth not progressing normally — see relevant emergency procedure

• Childbirth is a natural event. Most women give birth without active help • At normal birth, woman needs to

◦ Have company of anyone she chooses ◦ Feel safe and encouraged ◦ Be free to make noise, give birth in any position she chooses

Labour • Labour pains are caused by tightening of uterus (contractions)

◦ Between contractions uterus is relaxed ◦ During contractions uterus tightens. Put your hand on woman's abdomen

to feel this happening ◦ Each contraction pushes baby down on cervix and it opens a little more

• Labour has started when ◦ Regular, painful contractions. Usually lasting 1 minute every 2–5 minutes

• Waters have broken (membranes ruptured) when ◦ Clear fluid (liquor) loss from vagina. Doesn't always mean birth will

happen soon • Colour of liquor (waters) can be

◦ Clear — normal ◦ Bloody — mixed with mucus ('show'), normal unless 'frank' blood loss ◦ Greenish/brown — meconium (baby poo) stained, baby may be distressed

• Baby is coming when ◦ Uncontrollable urge to push, grunting, wants to go to toilet, perineum or

anus bulging AND/OR part of baby seen when labia parted — usually head ▪ If bottom or feet seen— see Breech birth (p44) ▪ If cord seen — see Cord prolapse straight away (p39)

If woman arrives pushing and birth about to happen — see Getting ready to birth baby (p172)�

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Labour and birth

First stage of labour From start of labour until cervix fully dilated .

First check in labourCheck — as much as you have timeAsk woman, check file notes, have helper phone hospital or other clinics for relevant information.

• Ask ◦ Is there more than one baby ◦ Is baby moving ◦ When labour (pains) started

• What is happening now ◦ Contractions

▪ How often, how long — ask woman to tell you each time one starts, time over 10 minutes

▪ How strong — mild, moderate, strong ◦ Membranes intact or ruptured. If fluid loss — when did it start, how

much, colour, smell, blood or mucus ◦ If urge to push — can you see baby

• Obstetric history ◦ When baby is due ◦ Antenatal care — problems or infections during pregnancy, medical or

obstetric, eg positive GBS, untreated STI, diabetes, anaemia, UTIs ▪ Obstetric ultrasound report — number of babies, position of placenta ▪ Blood group, latest test results

◦ Number of previous pregnancies, number of live births, types of birth, multiple births

◦ Problems during or after past births, eg high BP, pre-eclampsia, bleeding after birth (postpartum haemorrhage)

• Medical history ◦ Medicines, allergies, substance use ◦ Bleeding disorders, diabetes, heart disease, kidney disease, high BP

Check • Every 15 minutes

◦ Baby's heart rate

If women less than 37 weeks pregnant — see Preterm labour (p23)�Min

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171Labour and birth

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• Every 30 minutes ◦ Woman's pulse BP, RR ◦ Contractions over 10 minutes — how often, how long, how strong ◦ Vaginal fluid loss — colour of liquor, blood loss

• Every 2 hours ◦ Ask woman to try to pass urine, do U/A ◦ Woman's temp

• Every 2–4 hours ◦ Palpate abdomen, check that baby's head (or presenting part) is moving

down into pelvis

Do • Medical consult to talk about

◦ Stopping labour (p29) ◦ Sending to hospital ◦ Oxytocin (eg Syntocinon) for delivery of placenta, and if bleeding after

birth (p55) • Put clean pad between women's legs and monitor loss

◦ Small amount of blood and mucus ('show') normal ◦ If more than 50ml vaginal bleeding — see Antepartum haemorrhage (p13) ◦ If green or brown vaginal fluid loss (meconium-stained liquor) — see Fetal

distress in labour (p37) • Let woman be in any position that makes her comfortable

◦ If woman wants to lie down — encourage her to use wedge to tilt her to left side

Normal observations • Temp — less than 37.5°C

◦ If more than 37.5°C — see Group B Streptococcus (p156) • Pulse — less than 100 beats/min • BP — less than 140/90mmHg • U/A — no more than trace of ketones or protein. Blood and leucocytes

common but need medical consult • Vaginal fluid loss — clear or pink • Uterus — soft and no pain between contractions • Contractions — become stronger, last longer, closer together • Baby's head (or presenting part) — continues to move down into pelvis • Baby's heart rate — 110–160 beats/min. If baby's heart rate not normal —

see Fetal distress in labour (p37)

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Labour and birth

◦ Upright positions help labour/birth more than lying on back — F 4.1 for examples

• If birth to progress, put in 1 or if possible 2 IV cannula (16–18G) with bung, as soon as you can (CPM p85) ◦ Birth is natural and not usually dangerous, but in remote clinic you need

to be ready in case something goes wrong

Second stage of labourFrom cervix fully dilated until birth of baby.

Getting ready to birth babyDo — first

• Get help — don't leave woman alone ◦ Have helper collect equipment (p166)

• If you have incubator — turn it on, needs time to heat up (p194)

Check • When pushing — check baby's heart rate during and after every contraction

If baby's heart rate less than 110 beats/min or more than 160 beats/min — it may be distressed.

• Change woman's position, eg if lying on back tilt to left side or sit up • Midwife/obstetrician consult, see Fetal distress in labour (p37)

4.1

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Do • Put in 1 or if possible 2 IV cannula (16–18G) with bung as soon as you can,

if not already in place (CPM p85)

Birthing the baby

• Be aware: Woman may pass faeces when straining to push. Normal but can be embarrassing for her. Gently remove, wiping away from baby

• Let woman birth baby in any position she wants, but remind her upright positions are best — F 4.1 for examples (p172) ◦ If she chooses to lie down — encourage her to lie on her left side or

put wedge under right hip to tilt to left. Lying flat on her back can be dangerous for mother and baby

• Have helper read out these instructions as you go along

Do • Put clean sheet under woman • Use small combines to clean any 'show' or faeces from perineum. Wipe from

front to back, then throw in bin • Open and set up birthing pack, put on clean pair of gloves • Put on eye protection • Check baby's heart rate between contractions • Talk calmly. Say things like "You are letting this baby out so well, everything's

stretching nicely", "That's great, let the baby out slowly"

Birth of baby's head and shoulders • Let birth of head happen slowly on its own

◦ On all fours — F 4.2, F 4.3, F 4.4 (p174) ◦ On back — F 4.5, F 4.6, F 4.7 (p174)

• If baby's head coming too fast — ask woman to pant or puff through contraction . Slows down birth, helps stop perineum tearing

In normal birth • Baby will

◦ Arrive (present) head first, usually with face towards mother's back ▪ If bottom or feet first — see Breech birth (p44) ▪ If cord first — see Cord prolapse (p39) straight away

◦ Have heart rate during labour of 110–160 beats/min ◦ Be bluish at birth, but become pink with first few breaths

• Vaginal discharge will be clear or pink before birth, may be mucoid and/or bloody, should not be green or brownish

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Labour and birth

• If membranes still intact and bulging — pop with gloved finger • Wait for next contraction — will take about 1 minute. As contraction starts,

baby's head usually turns to face woman's inner thigh — F 4.8, F 4.9

• As woman pushes with contraction , shoulders should deliver • Shoulder under pubic bone (anterior) comes out first

4.8 4.9

4.5

4.6

4.7

4.2

4.3

4.4

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If shoulder doesn't come out easilyIf woman birthing on all fours

• Wait for next contraction . Holding baby's head between your hands, gently lift up towards ceiling to release anterior shoulder — F 4.10

• When shoulder comes out from under pubic bone, ask woman to stop pushing. Gently guide baby downwards towards bed/floor — F 4.11

• Other shoulder should now appear — F 4.11If woman birthing on her back

• Wait for next contraction. Holding baby's head between your hands, gently pull down towards bed to release anterior shoulder — F 4.12

• When shoulder comes out from under pubic bone, ask woman to stop pushing. Gently lift baby upwards towards ceiling — F 4.13

• Other shoulder should now appear — F 4.13

Birth of body • Support head and shoulders while waiting for rest of body to slip out. May

happen straight away, or not until next contraction • Support baby as it births. It will be slippery, so get gentle but firm grip. Can

use warm towel

4.10 4.11

4.12 4.13

If shoulders still stuck — see Stuck shoulder straight away (p41)�

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Labour and birth

After the birth • Make sure there is only 1 baby by feeling woman's uterus. Top of uterus

should be no higher than umbilicus ◦ If there is another baby do not give oxytocin� See Birth of twins (p50)

• Give oxytocin (eg Syntocinon) IM 10units in thigh ◦ Placenta should separate within a few minutes. Without oxytocin

separation may take longer

Immediate care of baby • Put baby skin-to-skin on mother's chest/abdomen. If mother doesn't want

baby on her — put baby between her legs, away from blood and mess • Note time of birth • Dry baby very well, remove wet towel, cover baby with warm dry towel,

make sure head is covered • Do 'rapid assessment' of baby's condition

◦ Breathing or crying ◦ Muscle tone ◦ Heart rate

• If baby breathing, good muscle tone, heart rate more than 100 beats/min — leave in skin-to-skin contact with mother if possible ◦ OR If baby needs extra care — give to helper, see Newborn needing special

care (p72) ◦ OR If mother tired or unwell — give baby to family member ◦ Check heart rate, RR, tone, response to stimulation, colour at 1 minute for

APGAR score (p191) • Have helper

◦ See Keeping baby warm after birth (p193) ◦ Watch baby closely over next few minutes for sign of respiratory distress ◦ Check APGAR score (p191) again at 5 minutes

▪ If less than at 1 minute — see Newborn resuscitation straight away (p66) ◦ Encourage early breastfeeding — helps placenta separate from uterus,

uterus to contract after placenta delivered • See Care of normal newborn for first 24 hours for ongoing care (p196)

If baby floppy and/or not breathing properly and/or heart rate less than 100 beats/min — see Newborn resuscitation straight away (p66)�

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177Labour and birth

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Clamp and cut cord • Some cultures like long cord left on baby, ask

mother or support person • Wait for 3 minutes or until cord stops pulsating

if possible • Put 2 metal clamps on cord 5cm apart, at least

10cm from baby's abdomen — F 4.14 • Cut cord between 2 clamps with sterile blunt-

end scissors • Do not take clamps off after cutting

Taking cord blood

• If before placenta delivered ◦ Unclamp metal clamp on placenta side of cord ◦ Let blood flow into clean kidney dish ◦ Reclamp ◦ Use syringe to draw up 10ml of cord blood, put into labelled EDTA or plain

specimen tube • If after placenta delivered

◦ Draw 10mls of blood from one placenta blood vessel with needle and syringe, put into labelled EDTA or plain specimen tube

Third stage of labour From birth of baby until placenta delivered.

• Watch blood loss closely. Collect clots in kidney dish to measure later ◦ Normal loss is under 500ml (2 cups), but can seem like a lot of blood

• Deliver placenta ◦ If oxytocin given — see Delivering placenta with controlled cord traction

(p178) ◦ If oxytocin not given — see Delivering placenta by maternal effort (p179)

• Check for tears of birth canal (p184) • STI check

◦ Syphilis serology ◦ Full STI check if STI status unknown (p251) ◦ Combined vaginal and anal swab if GBS status unknown (CPM p419)

Very important if woman Rh(D)-negative or blood group not known.

If twins — only deliver placenta/s after birth of second baby.

4.14

5cm10cm to

baby

Cut

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Labour and birth

Delivering placenta with controlled cord tractionDo not

• Do not do controlled cord traction if oxytocin (eg Syntocinon) not available or woman refuses to have it — see Delivering placenta by maternal effort (p179)

Do • Woman lying or half sitting on bed, with kidney dish between her legs • Check oxytocin (eg Syntocinon) given — IM 10units into thigh • Clamp and cut cord if not already done • Watch for signs that placenta has separated from wall of uterus — trickle

or gush of blood from vagina, and lengthening of cord • Take metal clamp off cord, put back on close to

vagina. Put fingers around clamp — F 4.15, or wrap cord around hand

• Put other hand above pubic bone with palm facing away from you. Use arch formed between thumb and first finger, push in and up to support uterus and hold it in place — F 4.15 ◦ If cord goes back in when pushing in and up on

uterus — placenta hasn't separated properly. Wait a few minutes before trying again

• Apply gentle traction (pull) on cord — down towards bed • If you can't feel any movement OR feel cord tearing— STOP

◦ Wait a few minutes for placenta to separate. If only small amount of bleeding, no hurry

• If you feel movement — keep applying gentle traction (pull) to cord until you see placenta at vaginal opening

• Hold placenta with both hands and slowly twist in one direction to peel membranes off wall of uterus ◦ Keep pulling slowly and gently as you twist, until whole placenta and

membranes are out ◦ Put placenta in kidney dish

• Straight after placenta delivered, check top of uterus (fundus). Usually found at level of umbilicus. Should be firm like a grapefruit ◦ If soft — see Rubbing up a contraction (p180)

• Check how much bleeding • Check placenta quickly to see if there are any pieces missing, put aside to

check again later (p181) • Record time placenta delivered

4.15

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179Labour and birth

Labour and birth

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Delivering placenta by maternal effortIf no oxytocin (eg Syntocinon ) available or woman refuses to have injection.

Do • Encourage breastfeeding as soon as possible after birth. Releases natural

hormone (oxytocin) that causes uterus to contract • Watch for signs that placenta has separated from wall of uterus — trickle

or gush of blood from vagina , and lengthening of cord • Woman may feel a contraction or heaviness in pelvis. Usually has urge to

push as placenta separates and drops down into lower part of uterus ◦ Encourage woman to push when she gets the urge ◦ May be easier in standing or squatting position or sitting on toilet or pan,

where gravity will help • As placenta delivers, collect in kidney dish • Straight after placenta delivered, check top of uterus (fundus). Usually found

at level of umbilicus. Should be firm like a grapefruit ◦ If soft — see Rubbing up a contraction (p180)

• Check how much woman is bleeding • Check placenta quickly to see if there are any pieces missing, put aside to

check again later (p181) • Record time placenta delivered

Finally • See Care of mother for first 24 hours after the birth (p182) • Record in file notes

◦ Date and time of birth ◦ Time of delivery of placenta ◦ How much blood woman lost

• Do nothing — let placenta be delivered by mother's effort only • Do not pull on cord at any stage. May cause more bleeding

• If placenta not delivered 1 hour after birth — medical consult, see Retained placenta (p189)

• If bleeding — see Primary postpartum haemorrhage (p55)

• If placenta not delivered after following these steps — medical consult • If placenta still not delivered 30 minutes after birth — see Retained placenta

(p189) • If bleeding — see Primary postpartum haemorrhage (p55)

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Labour and birth

◦ What you did, any problems you had, etc ◦ Any medicines, immunisations given to mother and baby ◦ If placenta and membranes complete or incomplete ◦ APGAR scores — 1 minute and 5 minutes after birth (p191)

• Complete birth registration forms (p199) • Don't forget to celebrate and debrief • If challenged or distressed by anything you saw or did — talk with

◦ Friends, colleagues, qualified counsellor ◦ Bush Support Services on 1800 805 391

Rubbing up a contractionUsing hands to stimulate uterine muscles to contract after delivery of placenta.

• After delivery of placenta and every 15 minutes for first hour, gently feel top of uterus (fundus). Should be hard and size of a grapefruit ◦ Warn woman, as top of uterus (fundus) very tender after birth

• Have baby breastfeed if possible. Helps uterus contract ◦ Important that baby feeds within first hour after birth. Most babies do

this themselves if held close to breast • Full bladder can stop uterus contracting, encourage woman to empty

bladder. If unable to void and heavy blood loss — put in catheter (CPM p410)

Do • Using one hand, firmly but gently rub top of uterus (fundus) • Keep doing this until it becomes firm. Will feel like a hard grapefruit or

tennis ball under your hand

If uterus stays relaxed • Uterus feels spongy and bulky, woman may keep trickling or gushing blood • Call for help • See Primary postpartum haemorrhage (p55)

Only rub up contraction if woman starts to bleed from relaxed uterus after delivery of placenta. Relaxed uterus will bleed heavily.

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181Labour and birth

Checking the placenta

• Check placenta and membranes after delivery to make sure they are complete • If pieces of placenta or membranes left inside — uterus can't contract

completely, can cause bleeding (postpartum haemorrhage) • Placenta may have cultural or personal significance, family may want to take

it home. Do not dispose of it until you have asked • If woman going to hospital — send placenta with her. Be sure it is labelled

◦ Double bag then put in pathology transport container with ice brick

Do • Look at cut cord. Usually 3 blood vessels, but sometimes only 2 — F 4.16 • Put placenta on table

with fetal (cord) side up. Should be smooth and shiny — F 4.17

• Hold placenta up by cord and check membranes are intact — F 4.18 ◦ Note any holes,

tears, ragged edges — F 4.19

• Lay placenta flat on table with maternal side up — check it is complete ◦ Note if any pieces missing — F 4.20

4.184.19

4.20Piece (lobe) missing

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4.174.16

Blood vessels

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Care of mother for first 24 hours after the birth

• If total blood loss more than 500ml (about 2 cups ) — see Primary postpartum haemorrhage (p55)

• For ongoing care after first 24 hours — see Postnatal care of mother (p207)

Check • Uterus contracted, vaginal blood loss, pulse

◦ Every 15 minutes for 1 hour, then hourly for 4 hours ◦ If uterus contracted — top of uterus (fundus) will be firm, central, at level

of umbilicus ◦ Slow continuous trickle of blood can result in large loss. If this may be

happening — see Primary postpartum haemorrhage (p55) • Temp, BP, RR — hourly for 4 hours

Blood tests • FBE (best done 24 hours after birth), syphilis serology • If woman Rh(D)-negative with no Anti-D antibodies and baby Rh(D)-positive

— may need RhD-Ig (anti-D) IM 625units (125mcg) ◦ Take blood for

▪ Blood group antibody screen (if not done in pregnancy) ▪ Kleihauer test (within 2 hours of birth)

◦ Medical consult • If no antenatal care — take blood for first antenatal visit tests (p82) • Cord bloods

◦ If woman Rh(D)-negative or blood group unknown — ask for blood group, blood group antibody screen, direct Coombs test, FBE

◦ If woman Rh(D)-positive — ask for blood group, FBE

Do — in first hour • If mother comfortable — put baby on her chest, encourage skin-to-skin

contact and breastfeeding (p210). Offer help if needed • Woman should try to pass urine

◦ Full bladder can stop uterus contracting and cause heavy bleeding. Offer woman something to drink and eat, shower, change of clothing

• Make sure placenta checked (p181) and is complete • Medical consult about birth. Make sure you know mother's medical and

obstetric history. Talk about ◦ Labour, birth, condition of mother and baby ◦ Problems with woman, baby, placenta ◦ If need to send to hospital. If sending — send placenta, birth documents,

bloods, birth registration and family assistance forms with woman

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183Labour and birth

Care of mother for first 24 hours after the birth

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Do • Fill in forms for birth registration (p199), family assistance, perinatal

statistics • Encourage woman to move about to help prevent blood clots in her legs • If woman staying in community

◦ Mother and baby should rest in clinic for at least 4 hours, or as long needed after birth

◦ Make sure woman has passed urine before leaving clinic ◦ Make sure woman has someone staying with her to help look after baby

• Talk with woman about ◦ Emptying bladder regularly to lessen risk of heavy bleeding ◦ Perineal hygiene and healing — changing pads often, shower at least once

and preferably several times a day ◦ If perineal tear — use ice pack inside pad, (on for 20 minutes, off for 20

minutes) to help decrease pain and swelling in first 24 hours ◦ Teach woman how to feel top of her uterus, how to massage it to make

it hard if she has heavy bleeding . If heavy bleeding — someone to notify clinic staff as soon as possible

◦ Using paracetamol (CARPA STM p400) (doses p373) or paracetamol-codeine (CARPA STM p401) if needed for 'after-birth' pains — crampy abdominal pains, often worse when breastfeeding

◦ Breastfeeding (p210)

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Tears of the birth canal

Common after birth. Can be tear of perineum, vagina, vulva, or rarely cervix. Always check carefully.

• Tears can happen if ◦ Quick birth ◦ Baby's head big, large baby ◦ Presenting part big, eg baby's hand and arm coming out next to head

• If bright blood loss after delivery of placenta AND uterus firm and well contracted ◦ Look at vaginal area for tear ◦ If heavy bleeding but can't see bleeding tear — suspect cervical tear

Types of tears

Table 4.1: Tears of birth canal

Classification Type of damage

Superficial graze1st degree tear

Skin and superficial tissue only

2nd degree tear Skin and muscle of perineum — F 4.21

3rd degree tear Extends into anal sphincter, partial or fully

4th degree tear Extending beyond anal sphincter into rectal mucosa

Episiotomy Can extend into 3rd or 4th degree tear

Anterior genital tear Can involve urethra, labia, clitoris

If heavy bleeding at any time — see Rubbing up a contraction (p180), Primary postpartum haemorrhage (p55)�

4.21

Muscle layer of tear

Skin layer of tear

Urethra

Vagina

Perineum

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185Labour and birth


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Check • Woman often very sore, embarrassed about this examination. Be gentle,

careful, sensitive • Reassure woman, offer nitrous oxide (eg Entonox ) if available for pain relief

and to help relax • Position woman lying down, bottom at edge of bed, knees bent up, feet

supported • Use good light, positioned properly • Put on sterile gloves • Mop up blood in vagina entrance with sterile gauze swabs • Check perineum, vulva, urethra, labia, clitoris

◦ Separate labia and look at vaginal opening ◦ Wrap sterile gauze around fingers, gently separate walls of vagina ◦ If tear/bleeding high up in vagina or hard to see — may need sterile

speculum examination • Check for 3rd or 4th degree tear — put gloved index finger into rectum, feel

for anal sphincter between thumb on outside and finger on inside. Should feel circular ridge of muscle around anus ◦ Check for small fibres that may indicate partial 3rd degree tear ◦ Change gloves after rectal examination

• Follow each tear to end to see where it stops

Do not • Do not suture tear or episiotomy unless trained

DoRepairing tear properly will control bleeding caused by perineal trauma. Start as soon as possible.

• Superficial graze — common, don't need to be sutured. Sting when passing urine. Advise to drink plenty of water and use urinary alkaliniser

• 1st degree tear not bleeding — treat as for superficial graze • 1st degree tear bleeding — apply pressure with sterile pad for 5–10 minutes

or until bleeding stops. Add ice pack into combine pad • 2nd degree tear — suture unless woman refuses. See Repairing tear or

episiotomy (p187) ◦ If not confident about repair — control bleeding, send to hospital

• 3rd or 4th degree tear — medical consult, send to hospital for repair by specialist

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• If woman being sent to hospital ◦ Ice pack to perineum for pain relief, ease swelling and bleeding (20

minutes on, 20 minutes off). Do not put ice pack directly on skin ◦ If tear bleeding — apply pressure with sterile pad for 5–10 minutes

▪ If bleeding continues — ask helper to apply pressure ▪ Recheck for bleeding after another 10 minutes pressure ▪ If still bleeding — medical consult again. May suggest putting in large

stitches at bleeding point, clamping bleeding point, packing vagina (record what is inserted)

▪ Keep applying pressure for as long as needed. Weigh pads to work out blood loss (1g = 1ml)

◦ If bleeding continues — put in IV cannula, largest possible (CPM p85) ▪ Take blood for FBE , blood group . Send in with woman ▪ Start normal saline 1L at 125ml/hour

◦ Medical consult about whether antibiotics needed ◦ If woman unable to pass urine — put in indwelling urinary catheter

(CPM p410) ◦ Reassure woman and family. Encourage her to hold and breastfeed baby

unless feeling very unwell ◦ Do routine observations for evacuation (p360)

Remember: Keep checking uterus is firmly contracted.

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187Labour and birth

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Repairing tear or episiotomy

Attention

• If local anaesthetic given to do episiotomy — make sure area is still anaesthetised before doing repair. Give more if needed

• Do not pull stitches too tight when suturing. Area may keep swelling

What you need • Sterile dressing pack • Chlorhexidine aqueous solution • 10–20ml lignocaine 1% , needles and syringe for infiltration • Sterile combine (small) • Sterile gauze swabs x 3 packets • Sterile suture pack with needle holders, scissors and toothed forceps • Sterile artery forceps (fine) • 2.0 or 3.0 absorbable synthetic suture (eg Vicryl, Vicryl Rapide, Dexon) • 30–40mm half-circle or tapered needle • Water-based lubricant for rectal examination • Sterile towels/drape • Ice pack • Combine or pad

What you do • Position woman so she is comfortable, you can see tear clearly • Lay out dressing pack and equipment • Count gauze squares, packs, needles — record count in file notes • Wash hands, put on sterile gloves • Clean site with chlorhexidine solution • Drape site with sterile towels/drape • Inject lignocaine 1% into whole site if needed — 10ml usually enough, but

can use up to 20ml over 1 hour ◦ Wait a few minutes, check area anaesthetised properly

Only do repair if skilled. • If you can't do repair

◦ Treat tear/episiotomy as open wound waiting to be sutured ◦ Most important to stop/control bleeding

▪ Apply pressure with pad ▪ Ask woman to keep legs together to hold pad in place ▪ Check blood loss often and reinforce pads as needed

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Repairing tear or episiotomy

• Check wound again. If tear too big for you to repair — stop now ◦ Control bleeding (p187), arrange to send to hospital

• May need to insert vaginal pack/combine to enable good visibility while suturing. Record in file notes, do not forget to remove it

• Start by repairing vagina first. Find apex of tear and put first suture 3–5mm behind it — F 4.22. Use continuous non-locking stitch

• Use these sutures (not too tight) ◦ Continuous non-locking stitch in vagina — F 4.23 ◦ Continuous non-locking stitch in muscle layer —

F 4�24 ◦ Continuous subcuticular stitch in skin of perineum —

F 4.25

• If vaginal pack/combine used while suturing — take out • Make sure bleeding has stopped • Do vaginal and rectal examinations — check

◦ Sutures haven't gone through rectal mucosa ◦ No openings between vagina and rectum ◦ Sphincter feels intact

• Count gauze squares, packs, needles again, make sure count is correct, record number in file notes

• Put on ice pack (not directly on skin) then combine pad • Give pain relief (CARPA STM p399)

4.23 4.24 4.25

4.22

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189Labour and birth

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Retained placenta

• Placenta still inside uterus (not delivered), little or no bleeding ◦ 30 minutes after trying controlled cord traction (p178) ◦ OR After 1 hour of maternal effort to deliver

• Do not rush steps — check vaginal blood loss every 5 minutes. Watch for slow ongoing trickle of blood, can add up to large loss over time.

Check • Was oxcytocin (eg Syntocinon) given after birth of baby • Has woman passed urine

◦ If unable to pass urine — may need indwelling urinary catheter

Do • Put baby to woman's breast, encourage baby to start sucking • If woman had oxytocin — try controlled cord traction (p178) again

◦ If cord has lengthened — may need to move clamp closer to vulva • Ask woman to 'give a cough'

If placenta still not delivered after another 30 minutesReassure woman. Explain what you are going to do and why.

Check • Do vaginal examination. Use sterile gloves, water-based lubricant or

obstetric cream. With your fingers, follow cord up into vagina ◦ If you feel placenta in vagina or cervix — grasp and carefully pull out ◦ If you feel cord going through cervix — stop. Placenta retained. Do not try

controlled cord traction again • Check temp, pulse, BP, RR

Do not • Do not let woman eat or drink anything — may need operation

Do • Put in IV cannula, largest possible (CPM p85)

◦ Take blood for FBE, blood group. Send in with woman ◦ Start normal saline 1L at 125ml/hr

• Medical consult, arrange to send to hospital

Keep checking for vaginal bleeding. If heavy bleeding at any time (more than 500ml) — see Primary postpartum haemorrhage (p55)�

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Retained placenta

• Make up oxytocin (eg Syntocinon) infusion (40units in 1L normal saline) ◦ Do not connect or start running unless woman has heavy bleeding. Send

in with woman • Put in indwelling urinary catheter (CPM p410), if not already in place • Continue observations until sent to hospital (p360)

If placenta delivers — see Rubbing up a contraction (p180)�

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191Labour and birth

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APGAR Score

Used to help assess wellbeing of newborns. • If baby non-responsive — start resuscitation straight away. Do not wait for

first APGAR score

Do • Score each of the 5 signs between 0 and 2 — to give total score out of 10.

See Table 4.2 (below) • Check APGAR scores at 1 minute and 5 minutes after birth • For sick babies keep checking every 5 minutes until score of 8 or more, or for

20 minutes

Table 4.2: APGAR score

APGARsign

Score0 1 2

A ppearance (central colour)

Grey, blue, pale Body pink but hands and feet pale or blue

Good colour, pink all over

P ulse (heart rate)

Absent Less than 100 beats/min

100 or more beats/min

G rimace (reflexes, response to stimulation)

No response Pulls a face, grimaces

Cough, sneeze when mucus cleared from mouth

A ctivity (muscle tone)

Arms/legs floppy Some flexion, elbows/knees a little bent

Flexed, all limbs moving well

R espiration (breathing)

Absent Slow, weak, irregular

Good, strong cry

To check baby's heart rate • Listen with stethoscope over lower left chest (apex) • OR Put 2 fingers over lower left chest to feel heartbeat • OR Feel at base of umbilical cord close to abdomen

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APGAR score

Record in file notes • Score • How long it took for baby to breathe normally • How long it took for baby to 'pink up' • How long before heart rate 100 beats/min or above

• Score 8–10 — Normal score, care for baby as usual (p196) • Score 4–7 — Low score, baby needs some help

◦ Ask helper to find Newborn resuscitation (p66) or Newborn needing special care (p72)

◦ While they are finding this ▪ If RR 40 breaths/min or less and/or heart rate less than 100 beats/min

— start assisted ventilation with neonatal bag and mask using room air at 40–60 breaths/min

▪ If RR more than 40 breaths/min — give oxygen through cupped hand over mouth and nose

• Score 0–3 — Very low score, baby needs help straight away ◦ Ask helper to find Newborn resuscitation (p66) ◦ While they are finding this, start assisted ventilation with neonatal bag

and mask using room air at 40–60 breaths/min ◦ If heart rate less than 60 beats/min after 30 seconds of ventilation —

start external chest compressions (CPR at ratio 3 compressions to 1 breath), attach bag and mask to oxygen 10L/min

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193Labour and birth

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Keeping baby warm after birth

• Babies lose heat very quickly, can quickly get cold after birth • Cold will stress baby, cause breathing problems (respiratory distress) or low

BGL (hypoglycaemia), make resuscitation more difficult

Attention • Best way to warm baby is against mother's skin

◦ Keep baby's head covered — where most heat lost ◦ Cover back of baby with bunny rug, sheet, clothing

• Do not ◦ Do not use hot water bottle ◦ Do not overheat baby in incubator or under overhead heater ◦ Do not bath baby until temperature normal — most don't need bath at all

What you need • Warm room for baby to arrive into

◦ Turn off air conditioner and put on heating just before birth ◦ If can't turn off air conditioner and warm outside — open doors and

windows • Lots of clean, pre-warmed towels, sheets, blankets. Warm by putting in sun,

wrapping around hot water bottle, putting in incubator or near heater • Bubble wrap, space blanket, cling wrap • Incubator (p194)

◦ Use only if mother or family member not able to hold baby OR baby has breathing problems and needs oxygen

◦ Must be warm, in good working order, free of dust

What you do • As soon as baby born, put onto mother's chest, skin-to-skin, and dry

thoroughly with warm dry towel

Risk factors for low temperatures • Low birth weight • Preterm • Sick • Resuscitated straight after birth • Breathing problems • Mother with diabetes • Born before arriving at clinic and has become cold

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• Remove wet towel and put new, warm one over baby's head and body, as baby lies on mother

• If mother not able to hold baby, and baby is pink and breathing well ◦ Ask helper/relative to put naked baby under their

clothes, against skin on their chest (chest-to-chest), add layers of space blankets/bubble wrap/towels around baby's body, cover head with hat or bunny rug

◦ OR Use clean, warm towel to wrap baby as snugly as possible, making sure head is fully covered to middle of brow — F 4.26 ▪ Wrap body (not head) again in bubble wrap/cling

wrap/space blanket ▪ Give to helper to hold and watch over

◦ OR Use incubator (below) • After placenta delivered and mother comfortable,

take baby's temp under arm (axillary). Make sure skin dry, thermometer snugly between folds of skin not clothing

• Wait until baby warm and settled with no signs of distress before weighing naked. Have all equipment ready before unwrapping baby

• Keep skin-to-skin with mother for as long as possible, encourage first breastfeed within first hour — F 4.27. Baby will warm up faster after a good feed

Using incubator or overhead heaterAttention

• Use heat shields to help reduce heat loss, eg bubble/cling wrap or space blanket over baby's body, hat or blanket for head

IncubatorAttention

• Cold incubator needs ½–1 hour to warm up so try and think ahead in an emergency. Do not put baby in until right temperature

Baby's temperature shouldn't go up or down more than 0.5–1°C in an hour. Baby can't adjust well to rapid changes in temperature, will show signs of distress�

Do not use incubator if you don't know how to operate it.

4.26

4.27

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195Labour and birth


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What you do • Put baby into preheated incubator — see Table 4.3

◦ Make sure you can see baby from where you are working • Check baby's temperature at least every 15 minutes, adjust thermostat if

needed • Record at each check

◦ Temperature of baby and of incubator ◦ If you adjusted temperature and to what temperature

Table 4.3: Approximate incubator temperature settings on first day of life

Birth weight (g) °C

500 35.5 +/- 0.5

1000 35.0 +/- 0.5

1500 34.0 +/- 0.5

2000 33.5 +/- 0.5

2500 33.1 +/- 0.9

3000 33.0 +/- 1.0

3500 32.8 +/- 1.2

• Cover top of incubator with blanket or space blanket to slow heat loss ◦ Also blocks some light to baby, can lessen stress response and help baby

maintain temperature • Do not open incubator or portholes unless you have to, lets heat escape • Do normal observations as for any baby after birth (p196)

Overhead heaterWhat you do

• Keep checking baby isn't too close to heater, or too hot • Check and record baby's temperature at least every 15 minutes

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Care of normal newborn for first 24 hours

Immediate care of babies who didn't need active resuscitation at birth, and ongoing care of babies who remain well with no risk factors (p197)�

Immediate care after birth

Remember: Uncover baby as little as possible to keep warm.

Check • Temp under arm, heart rate, RR, O2 sats, colour

◦ Repeat every 15 minutes for first hour • Umbilicus for bleeding, clamp on properly • If any observations not normal or you are concerned — medical consult

Some babies at higher risk of becoming unwell in first 24 hours even if well at birth and need additional care. If baby has any risk factors (p197) — see Newborn needing special care (p72)

Do not • Do not rush to weigh baby. Wait until after first breastfeed

If baby's condition gets worse — call for help, see Newborn resuscitation flowchart (p64), medical consult straight away.

Normal observations for newborn baby • Temp — 36.5–37°C under the arm • Heart rate — 120–160 beats/min • RR — regular, 35–60 breaths/min

◦ No distress — no grunting, nasal flaring, chest in-drawing (sucking in of soft tissues around rib cage or neck)

• O2 sats — 90% or more in room air in after-birth period, then 95% or more • Colour — tongue and lips pink. Not pale or blue • Movement — active when awake, moving all limbs with good tone. Not

floppy or stiff • BGL — more than 2.6mmol/L • Feeding — gets started with breastfeeding. Not vomiting

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197Labour and birth


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Do • Continue skin-to-skin contact for as long as mother wants, then wrap baby

warmly • Encourage early breastfeeding (p210) • Trim cord

◦ Clamp remaining cord with plastic cord clamp 2–5cm from abdomen — F 4.28, then put second plastic clamp 2–3cm above in opposite direction — F 4.29. Make sure they snap shut

◦ Take off metal cord clamp. Trim cord 1–2cm above plastic clamps, or at length asked for by mother or support person

• Clean skin well with cotton wool and water before giving IM injections ◦ If mother positive for hepatitis B (HbsAg), hepatitis

C or HIV and baby more than 32 weeks gestation — wash injection site with warm water and chlorhexidine, dry thoroughly (keep warm)

• Give vitamin K (eg Konakion) ◦ 1mg (0.1ml) IM for baby weighing 1.5kg or more ◦ 0.5mg (0.05ml) IM for baby weighing less than 1.5kg

Ongoing care of normal newborn • If baby well — observations every hour for 4 hours • If GBS status of mother not known (no screening at 36 weeks) — continue

routine observations, including temp, every 6 hours for 24 hours

4.29

4.28

Risk factorsMother's history Labour and birth Newborn period

• No or little antenatal care (less than 4 visits)

• Diabetes • Alcohol and/or

other substance use • GBS positive • Current STI • High BP

• Mother needing help with birth

• Baby needing any resuscitation at birth

• Maternal fever in labour

• Meconium-stained liquor (green or brown amniotic fluid)

• Birth weight less than 2.5kg or more than 4.5kg

• Preterm (less than 37 weeks gestation)

• Congenital abnormality • Abnormal observations,

eg respiratory distress, low BGL, temperature instability

• Neurological — seizure, poor tone

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• If observations not normal, eg increased RR or heart rate, rash/redness to head, face or eyes — medical consult

• If baby jittery (jumpy) and unsettled, or not feeding within 3 hours after birth — check BGL, medical consult ◦ If BGL less than 2.6mmol/L — treat straight away (p74)

After first hour or first breastfeed • Head-to-toe check of baby — including abnormalities, birth marks, bruising

◦ If sending to hospital — can be done there ◦ If not sending to hospital — ask doctor or midwife how this is done

• Measure length, head circumference • Start file notes and growth chart • Check mother's hepatitis B results

◦ If mother HBsAg positive or status not known — give baby hepatitis B immunoglobulin IM 100units and hepatitis B immunisation IM 0.5ml at different sites ▪ Give hepatitis B immunoglobulin within 12 hours of birth ▪ If clinic does not have hepatitis B immunoglobulin — medical consult

◦ If mother HBsAg negative, give baby hepatitis B immunisation IM 0.5ml • Check mother's syphilis serology

◦ If active syphilis at any time during pregnancy or if syphilis serology not known — medical consult about treating baby

• If mother had recent infection, especially STI — medical consult • Continue to encourage breastfeeding

◦ Only contraindications — lesions on breasts, mother's medicines • Fill out birth registration forms (p199)

If mother and baby stay in community • Encourage mother to breastfeed baby on demand (p210) • Check baby has passed meconium and urine

◦ Cotton wool ball in disposable nappy can make it easier to check for urine ◦ If urine or meconium not passed after 18 hours — medical consult

• Talk with CDC/PHU about BCG immunisation • Talk with mother about care of umbilicus

◦ Clean with water and cotton wool, air dry ◦ Signs of infection, come to clinic straight away if any problems

• After 24 hours, see Postnatal care of baby (p241) • Review baby daily for first week

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199Labour and birth

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Birth registration forms

All births must be registered with state/territory register. Attending health professional must complete forms for births out bush, even if woman and baby sent to hospital, or health professional not present at actual birth.

To save time finding forms, ask local maternity service to send a few made-up bundles. Keep with other birthing equipment.

Follow instructions on forms, send to address given on each form. • Birth Registration Form/Statement — lodge within 60 days • Perinatal statistics form (also called Midwives/Perinatal Data Form) • Help parents if needed

◦ Newborn Medicare enrolment form ◦ Centrelink forms, eg Maternity Immunisation Allowance, Parenting

Payment

Health service requirements • Set up new client file notes • Start immunisation record • Add to population register and recall lists • Update community 'birth' book if applicable

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Stillbirth

Can be distressing, traumatic event for woman and family. Different cultures and language groups react in different ways. Women and family members may understand stillbirth differently, react and respond in different ways. Some Aboriginal women say that, in the old days, a baby who died soon after birth 'with the eyes still closed' was not a source of grief.

Listen carefully, be guided by ATSIHPs or AHWs, woman's relatives, woman herself. Look at way woman responds, change your approach to suit. Some younger women may have different cultural values from older members of their family.

Considerations for health staff, woman and family • Be guided by ATSIHPs or AHWs, family members for language to use. 'Passed

away', 'lost', 'finished' may be better understood, less offensive than 'died' • Woman and family members may or may not wish to see the baby. Ask

family member or woman herself. If they want to see and/or hold the baby — wrap in clean baby rug with face uncovered

• Family may name baby. Check if you should refer to baby by name • If baby goes to hospital with woman — mementos of baby, eg lock of hair,

clothing, photos, hand/footprints can be taken. Explain they will be kept in sealed container at hospital, family can have them if they want them

• Woman may want baby buried in home community. Relatives may want formal burial arranged, even if baby 'passed away' early in pregnancy. Can have important cultural and spiritual significance

• Father of baby may or may not be directly involved • Family may believe death caused by unacceptable behaviour of another

person, or series of events. May direct anger or frustration at clinic staff • You or community members may wish to close clinic for rest of the day • Allow family to spend the time they need with the baby • True stillbirth not reportable to Coroner. All other perinatal deaths

reportable, in first instance to police

Do • Medical consult about

◦ Stillbirth, for help in following this protocol ◦ Medical complications that may need to be managed in hospital,

antibiotics (if signs of infection), other concerns

• Any baby 20 or more weeks gestation or 400g or more in weight who doesn't show any sign of life at birth

• Pregnancy loss at less than 20 weeks gestation or less than 400g in weight is miscarriage (p9)

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201Labour and birth

Stillbirth

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Care for mother • Look after woman as the priority • Follow guidelines for postnatal care. See Care of mother for first 24 hours

after the birth (p182) • Strongly encourage woman to go to hospital with baby for support and care

◦ Mother may stay in community, let baby to be transferred to hospital ◦ Rare that mother and baby stay in community

• Explain that careful management and follow-up now may improve outcome or help prevent problems in future pregnancies. Operation on baby to find cause of death (autopsy) recommended for same reasons

If mother agrees to go to hospital • Medical consult to arrange to send to hospital straight away • Baby must be identified with name band on each leg • Offer mother option of holding baby, wrapped in appropriate blanket during

transfer� Talk with retrieval doctor about her wishes • Send placenta • Tests for mother and baby, discussion about autopsy will happen in hospital

If mother does not go to hospital • Offer tests in Table 4.4 (p202)

◦ Tests aim to find cause of stillbirth, to offer mother best care options • Talk later about suppressing lactation (p213). Can use simple measures or

take medicine. Milk usually produced within a few days even if baby stillborn

Management of baby

If woman doesn't go to hospital — discuss autopsy for baby with her • Autopsy strongly recommended, need to discuss with family • Written consent must be given — make sure they understand fully • Explain it may help find out why this baby died, help future pregnancies • Explain baby will be treated with dignity, skin incisions will be minimal

Remember: Family makes this decision — they may not agree.If mother consents to autopsy for baby

• Get consent form from Maternity Unit. Best if mother signs consent form. If situation complicated (eg family disagreement, another family member plans to sign form) — medical consult

• Write letter which includes ◦ Details of any previous pregnancies ◦ Details about this pregnancy, including any problems ◦ Details about labour and birth, including birth weight, time of birth ◦ Antibiotics or other medicines taken in pregnancy ◦ Substance use, eg smoking, alcohol, petrol sniffing, during pregnancy

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Stillbirth

• Ask for medical report and plain English autopsy report to be sent to clinic

Table 4.4: Pathology specimens

Sample from Blood Swab Urine

Mother • Serology ◦ Syphilis ◦ Toxoplasmosis ◦ Rubella ◦ Herpes ◦ Cytomegalovirus ◦ Parvovirus B19 ◦ Hepatitis B

• Thrombophilia (blood clotting problems) ◦ Protein C ◦ Protein S ◦ Anti-thrombin III ◦ Homocysteine ◦ Activated protein C

resistance ◦ Anticardiolipin

antibodies ◦ Lupus anticoagulant ◦ Kleihauer test

(within 24 hours) • FBE • Blood group • Antibody screen • HbA1c • BGL • Blood cultures

(if febrile or signs of infection)

• If speculum examination – HVS/endocervical

• OR If no speculum examination – LVS ◦ MC&S ◦ NAAT for

gonorrhoea, chlamydia, trichomonas

• MC&S • If no swabs

– NAAT for gonorrhoea, chlamydia, trichomonas

Baby • Cord blood ◦ Chromosomes

Placenta • Cord blood (from placental or baby cord)

• Baby's side of placenta (side cord comes out) ◦ MC&S

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203Labour and birth

Stillbirth

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Transporting autopsy specimens • Baby

◦ Put name bands on both legs ◦ Wrap, then put in plastic bag

• Placenta — put in separate sealed plastic bag • Do not use formalin or saline • Transport in esky with 4 large ice bricks

◦ Seal with sticky tape run right around edge of lid ◦ If being transported on aircraft (RFDS or otherwise) — put sealed esky

inside additional plastic bag, seal bag completely so no leakage • Include baby's cord blood, consent form for autopsy, letter, pathology

request form • Make sure all checks and documentation complete

If mother doesn't consent to autopsy for baby • Carry out basic examination of baby, document findings clearly • Check

◦ Placenta — completeness, texture, cord vessels. Check for knot in cord ◦ Take cord blood — may be difficult. Collect blood directly from cord

before it is clamped OR use normal blood collection equipment to perform venipuncture on 1 vessel of cord

◦ Baby ▪ Any obvious abnormalities ▪ Record appearance, take photos if parents consent. May help

paediatrician diagnose congenital abnormalities ▪ Document weight, length, head circumference ▪ Assess gestational age if possible

◦ If asked by family — collect mementos, eg lock of hair • Medical consult or talk with clinical coordinator about how to manage baby.

Follow health service guidelines

Documentation • Complete all documentation as soon as possible after baby's death, lodge

forms straight away • Compete labour/birth details as relevant • Birth Registration Statement appropriate for state/territory of birth

◦ Complete, lodge within 60 days • Medical Certificate of Cause of Perinatal Death completed by doctor • Fill in perinatal statistics form, send to Perinatal Statistics Unit • Woman entitled to Centrelink maternity payments

◦ Forms need to be lodged within 26 weeks of stillbirth

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Stillbirth

Follow-up • Medical consult about autopsy report and other results • If results affect future pregnancies — arrange obstetrician review. Talk with

woman about risk, important to be seen early for antenatal care • Give woman opportunity to talk about what happened. Arrange time to talk

about results of tests with woman and family if they want to know • See Postnatal care of mother (p207)� Mother's 6 week postnatal check still

important (p231). Look for signs of perinatal depression (p233) • If more support needed — refer woman to social worker • Talk about contraception

Stillbirth or neonatal death can be very distressing and traumatic for staff involved. Feelings can persist. Important to debrief after these events and support each other in this process. See Coping after emergencies (p6)�

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Documents

4 Labour and birth - IEmpowermentiempowerment.org/usb/iempowerment/healthcare/Health_Womens_Business...Labour and birth 4 Labour and birth ... Retained placenta ... Manual, 5th ed